“We have embraced a mission” to serve the poor, says Dr. Charles Vega, who directs the residency program for family medicine at UC Irvine. The school does not have the funding to increase the number of doctors it trains – about nine per year in family medicine. Those doctors are working out of the UC Irvine Family Health Center in downtown Santa Ana. H. LORREN AU JR., ORANGE COUNTY REGISTER

UC Irvine Family Health Center in Santa Ana is located downtown at 800 N. Main Street. Once their resident training ends here, many of the young doctors in the program will practice in low-income communities.. H. LORREN AU JR., ORANGE COUNTY REGISTER

Why it matters

The Affordable Care Act is supposed to extend health care to millions of Californians who don't have it today. But the state's primary care doctors are already in short supply. Without more doctors or changes to the way they practice, patients might face long waits to get care or have trouble finding a doctor at all.

More to come

Watch for these stories in the coming weeks:

Community clinics. California's community clinics have long served the poor, but they will soon be competing for that business.

Obamacare at work: How big employers in O.C. and nationally are rethinking their relationship to employee health coverage in the shadow of Obamacare.

Readers: Send questions about Obamacare to Emily Bazar, who writes the Ask Emily column for the Register, at AskEmily@usc.edu. Suggestions for Register coverage can go to editors Mark Matassa (mmatassa@ocregister.com) or Dan Beucke (dbeucke@ocregister.com)

Part 8 in a series

The Affordable Care Act promises to bring insurance to millions of Californians who don't have it now. But will it bring them health care?

The law expands the Medi-Cal program for the poor and offers subsidies for low-income and middle-class people to buy private coverage through a new online marketplace known as Covered California.

That assistance is expected to provide insurance to at least 2.5 million people, many of whom have depended on free clinics and hospital emergency rooms for their care. Now, in theory, they will have regular doctors, and many have unmet health issues that require attention.

But California already faces a shortage of family doctors, and some fear that the influx of new patients could overwhelm the physician workforce.

“It's important to keep in mind that insurance does not equal access to care,” said Dr. Brennan Cassidy, a Newport Beach physician and former president of the California Medical Association.

California has about 22,000 primary care doctors, or about 60 for every 100,000 residents, the minimum number recommended by the Council on Graduate Medical Education to provide adequate access to patients.

Orange County has about 6,000 doctors, and about a third practice primary care. That's about 65 primary care doctors for every 100,000 county residents.

But the bigger problem, statewide and in Orange County, is where those doctors practice.

Statewide, fewer doctors practice in rural areas or in poor communities, making it even more difficult for people in those places to get care.

The problem is especially acute in Medi-Cal, the state program that provides free care to the poor. California's program has some of the lowest costs per patient of any state, but that is largely because the state pays doctors so little to care for Medi-Cal patients.

The result: Fewer and fewer doctors accept patients through the program, and finding one near home can sometimes be impossible. Compounding the problem is the fact that low-income people also often have limited transportation options, making a trip across town to reach a doctor's office impractical.

LONGSTANDING PROBLEM

The shortage of doctors in Medi-Cal is a longstanding problem, but the same issue might also affect consumers who buy coverage through the Covered California. While the state has established minimum standards for the doctor networks in the plans sold by the insurance companies through the new exchange, some of the plans are going to have fewer doctors than similar coverage available on the private market.

“We might not have this problem if the insurance companies and Medi-Cal would contract with all the doctors who want to be part of their networks,” said Assemblyman Richard Pan, a Sacramento Democrat and practicing pediatrician.

But the problem is cost. The fewer doctors in a network, the less an insurance company, or a public health care plan, has to pay to contract with its providers. If they contracted with more doctors, that would likely drive up the cost of their coverage, making it less affordable. So it's a trade-off.

For Medi-Cal, at least, the Affordable Care Act addresses the shortage by increasing reimbursements to the level the federal government pays for doctors who see Medicare patients. In California, that will mean a doubling of rates for many visits and procedures, and sometimes more. But the feds will pay for the higher reimbursements for only two years.

TRAINING MORE DOCTORS

California is also trying to address the problem by ramping up two new medical schools at UC Merced and UC Riverside. Both will have a focus on serving rural areas and low-income people.

Increasingly, that is also the mission of the family medicine program at UC Irvine.

“We have embraced a mission” to serve the poor, said Dr. Charles Vega, who directs the residency program for family medicine at UCI. The school does not have the funding to increase the number of doctors it trains – about nine per year in family medicine – but those doctors are working out of the UC Irvine Family Health Center in Santa Ana. After that exposure, many will continue to practice in low-income communities once they end their training.

In the long term, though, the answer may come in asking doctors to delegate some of their duties to other professionals. The state is rolling out a pilot program in which paramedics will do some health screenings and follow-ups with people in their communities. And there is pressure to allow nurse practitioners to practice in California without a doctor's supervision, which they do in many states. A bill in the Legislature to allow that was shot down by the medical community this year, but the issue won't be going away.

Something will have to give. Without significant change throughout the system, it is difficult to see how California is going to fulfill the promise of bringing affordable care, not just insurance coverage, to the millions who don't have access to it today.

Daniel Weintraub has covered public policy in California for 25 years. He is editor of the California Health Report at healthycal.org. Reach him at daniel.weintraub@gmail.com

CALIFORNIA'S DOCTOR SHORTAGE

Q. Is there a shortage of doctors in California?

A. According to one study, California has about the minimum number of primary care doctors recommended by the federal government for the state's population – about 60 for every 100,000 people. But many of those doctors will be retiring soon, and the Affordable Care Act is going to give many more people access to insurance coverage and health care, which will probably increase demand for services.

Q. How many more people will be needing care?

A. About 1.4 million Californians will be added to the Medi-Cal rolls next year, and another million more are expected to buy insurance through the state's new online insurance marketplace. Not all of these people have been going without care, but many have not had a regular doctor. And studies show that people who are newly covered by health insurance tend to go to the doctor more often, probably to catch up with conditions they have been enduring.

Q. Is the shortage worse in some areas than others?

A. Yes, low-income and rural communities have the worst shortage of doctors, in part because those places tend to be tougher to practice in and less pleasant places to live. Medi-Cal patients sometimes struggle to find a doctor who will see them because the state's reimbursement rates for physicians are low and many doctors do not have contracts with the county plans that manage Medi-Cal for the state.

Q. What can be done to increase the number of doctors?

A. The state is ramping up two new medical schools, at UC Merced and UC Riverside. Medical schools also have been encouraging more students to go into family medicine, where the need is greatest, and there are programs that forgive some or all of a doctor's college loan debt if he or she serves for a time in the communities that are most in need. Health plans also could contract with more doctors who want to see patients but have not been included in the companies' networks.

Q. Can anything else be done?

A. Some have proposed expanding the duties of other medical professionals, including nurse practitioners and midwives, to do some of the things doctors do now. But physician groups usually oppose these changes, arguing that they would put patients at risk.

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